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§5208. Asbestos, Appendix D

Medical Questionnaires

Manditory

This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos above the permissible exposure limit, and who will therefore be included in their employer's medical surveillance program. Part 1 of the appendix contains the Initial Medical Questionnaire, which must be obtained for all new hires who will be covered by the medical surveillance requirements. Part 2 includes the abbreviated Periodical Medical Questionnaire, which must be administered to all employees who are provided periodic examinations under the medical surveillance provisions of the standard.

Part 1
INITIAL MEDICAL QUESTIONNAIRE
1. NAME ________________________
2. SOCIAL SECURITY #
____ ____ ____ ____ ____ ____ ____ ____ ____
1 2 3 4 5 6 7 8 9
3. CLOCK NUMBER ____ ____ ____ ____ ____ ____
10 11 12 13 14 15
4. PRESENT OCCUPATION ________________________
5. PLANT ________________________
6. ADDRESS ________________________
7. ________________________________
(Zip Code)
8. TELEPHONE NUMBER ________________________
9. INTERVIEWER ________________________
10. DATE ________________________ ____ ____ ____ ____ ____ ____
16 17 18 19 20 21
11. Date of Birth ________________________ ____ ____ ____ ____ ____ ____
Month Day Year 22 23 24 25 26 27
12. Place of Birth ________________________
13 Sex
1. Male ____
2. Female ____
14. What is your marital status?
1. Single ____ 4. Separated/
2. Married ____ Divorced ____
3. Widowed ____
15. Race
1. White ____ 4. Hispanic ____
2. Black ____ 5. Indian ____
3. Asian ____ 6. Other ____
16. What is thew highest grade completed in school? ________
(For example 12 years is completion of high school)
OCCUPATIONAL HISTORY
17A. Have you ever worked full time (30 hours
per week or more) for 6 months or more?
1. Yes ____ 2. No ____
IF YES TO 17A:
B. Have you ever worked for a year or more in
any dusty job?
1. Yes ____ 2. No ____ 3. Does Not Apply ____
Specify job/industry
Total Years Worked ____
Was dust exposure:
1. Mild __ 2. Moderate __ 3. Severe __
C. Have you even been exposed to gas or
chemical fumes in your work?
1. Yes ____ 2. No ____
Specify job/industry __________________________________
Total Years Worked ____
Was exposure:
1. Mild __ 2. Moderate __ 3. Severe __
D. What has been your usual occupation or job--the one you
have worked at the longest?
1. Job occupation __________________________________
2. Number of years employed in this occupation _____
3. Position/job title ______________________________
4. Business, field or industry _____________________
(Record on lines the years in which you have worked in any
of these industries, e.g. 1960-1969)
Have you ever worked:
YES NO
E. In a mine?........................ [ ] [ ]
F. In a quarry?...................... [ ] [ ]
G. In a foundry?..................... [ ] [ ]
H. In a pottery?..................... [ ] [ ]
I. In a cotton, flax or hemp mill?... [ ] [ ]
J. With asbestos?.................... [ ] [ ]
18. PAST MEDICAL HISTORY
YES NO
A. Do you consider yourself to be in good health?... [ ] [ ]
If "NO" state reason __________________________________
B. Have you any defect of vision?................... [ ] [ ]
If "YES" state nature of defect _______________________
C. Have you any hearing defect?..................... [ ] [ ]
If "YES" state nature of defect _______________________
D. Are you suffering from or have you ever suffered from:
a. Epilepsy (or fits, seizures, convulsions)?.. [ ] [ ]
b. Rheumatic fever?............................ [ ] [ ]
c. Kidney disease?............................. [ ] [ ]
d. Bladder disease?............................ [ ] [ ]
e. Diabetes?................................... [ ] [ ]
f. Jaundice?................................... [ ] [ ]
19. CHEST COLDS AND CHEST ILLNESSES
19A. If you get a cold, does it usually go to your chest?
(Usually means more than 1/2 the time)
1. Yes __ 2. No__ 3. Don't get colds __
20A. During then past 3 years, have you had any chest illnesses
that have kept you off work, indoors at home, or in bed?
1. Yes __ 2. No__
I YES TO 20A
B. Did you produce phlegm with any of these chest illnesses?
1. Yes __ 2. No__ 3. Does not apply __
C. In the last 3 years, how many such illnesses with (increased)
phlegm did you have which lasted a week or more?
Number of illnesses __ No such illnesses__
21. Did you have any lung trouble before the age of 16?
1. Yes __ 2. No__
22. Have you ever had any of the following?
1. Yes __ 2. No__
1A. Attacks of bronchitis?
1. Yes __ 2. No__ 3. Does Not Apply__
IF YES TO 1A:
B. Was it confirmed by a doctor?
1. Yes __ 2. No__
C. At what age was your first attack?
Age in Years __ Does Not Apply__
2A. Pneumonia (include bronchopneumonia)?
1. Yes __ 2. No__
IF YES TO 2A:
B. Was it confirmed by a doctor?
1. Yes __ 2. No__ 3. Does Not Apply__
C. At what age did you first have it?
Age in Years __ Does Not Apply__
3A. Hay fever?
1. Yes __ 2. No__
IF YES TO 3A:
B. Was it confirmed by a doctor?
1. Yes __ 2. No__ 3. Does Not Apply__
C. At what age did it start?
Age in Years __ Does Not Apply__
23A. Have you ever had chronic bronchitis?
1. Yes __ 2. No__
IF YES TO 23A:
B. Do you still have it?
1. Yes __ 2. No__ 3. Does Not Apply__
C. Was it confirmed by a doctor?
1. Yes __ 2. No__ 3. Does Not Apply__
D. At what age did it start?
Age in Years __
24A. Have you ever had emphysema?
1. Yes __ 2. No__
IF YES TO 24A:
B. Do you still have it?
1. Yes __ 2. No__ 3. Does Not Apply__
C. Was it confirmed by a doctor?
1. Yes __ 2. No__ 3. Does Not Apply__
D. At what age did it start?
Age in Years __
25A. Have you ever had asthma?
1. Yes __ 2. No__
IF YES TO 25A:
B. Do you still have it?
1. Yes __ 2. No__ 3. Does Not Apply__
C. Was it confirmed by a doctor?
1. Yes __ 2. No__ 3. Does Not Apply__
D. At what age did it start?
Age in Years __ Does Not Apply__
E. If you no longer have it, at what age did it stop?
Age stopped __
26. Have you ever had:
A. Any other chest illness? 1. Yes __ 2. No__
If yes, please specify ___________________________________
B. Any chest operations? 1. Yes __ 2. No__
If yes, please specify ___________________________________
C. Any chest injuries? 1. Yes __ 2. No__
If yes, please specify ___________________________________
27A. Has a doctor ever told you that you had heart trouble?
1. Yes __ 2. No__
IF YES TO 27A:
B. Have you ever had treatment for heart trouble in the
past 10 years?
1. Yes __ 2. No__ 3. Does not apply __
28A. Has a doctor ever told you that you had high blood pressure?
1. Yes __ 2. No__
IF YES TO 28A:
B. Have you ever had treatment for high blood pressure
(hypertension) in the past 10 years?
1. Yes __ 2. No__ 3. Does not apply __
29. When did you last have your chest X-rayed? (Year) ______
30. Where did you last have your chest X-rayed (if known)?
______________________________________
What was the outcome? ______________________________________
FAMILY HISTORY
31. Were either of your natural parents ever told by a doctor
that they had a chronic lung condition such as:
FATHER MOTHER
1.Yes 2.No 3.Don't 1.Yes 2.No 3.Don't
Know Know
A. Chronic
Bronchitis? [ ] [ ] [ ] [ ] [ ] [ ]
B. Emphysema? [ ] [ ] [ ] [ ] [ ] [ ]
C. Asthma? [ ] [ ] [ ] [ ] [ ] [ ]
D. Lung cancer? [ ] [ ] [ ] [ ] [ ] [ ]
E. Other chest conditions? [ ] [ ] [ ] [ ] [ ] [ ]
F. Is parent currently alive? [ ] [ ] [ ] [ ] [ ] [ ]
G. Please Specify
_____Age if Living ____Age if Living
_____Age at Death _____Age at Death
_____Don't Know _____Don't Know
H. Please specify cause of death
______________________________ ______________________________
COUGH
32A. Do you usually have a cough? (Count a cough with first
smoke or on first going out of doors. Exclude clearing of
throat.) [If no, skip to question 32C.]
1. Yes __ 2. No __
B. Do you usually cough as much as 4 to 6 times a day
4 or more days out of the week?
1. Yes __ 2. No __
C. Do you usually cough at all on getting up or first thing in
the morning?
1. Yes __ 2. No __
D. Do you usually cough at all during the rest of the day
or at night?
1. Yes __ 2. No __
IF YES TO ANY OF ABOVE (32A, B, C, OR D), ANSWER THE FOLLOWING.
IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO NEXT PAGE.
E. Do you usually cough like this on most days for 3
consecutive months or more during the year?
1. Yes __ 2. No __ 3. Does not apply __
F. For how many years have you had the cough?
Number of Years __ Does Not Apply __
33A. Do you usually bring up phlegm from your chest?
(Count phlegm with the first smoke or on first
going out of doors. Exclude phlegm from the nose.
Count swallowed phlegm.) (If no, skip to 33C)
1. Yes __ 2. No __
B. Do you usually bring up phlegm like this as much
as twice a day 4 or more days out of the week?
1. Yes __ 2. No __
C. Do you usually bring up phlegm at all on getting
up or first thing in the morning?
1. Yes __ 2. No __
D. Do you usually bring up phlegm at all during
the rest of the day or at night?
1. Yes __ 2. No __
IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE FOLLOWING:
IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 34A.
E. Do you bring up phlegm like this on most days
for 3 consecutive months or more during the year?
1. Yes __ 2. No __ 3. Does not apply __
F. For how many years have you had trouble with phlegm?
Number of years __ Does not apply __
EPISODES OF COUGH AND PHLEGM
34A. Have you had periods or episodes of (increased*) cough
and phlegm lasting for 3 weeks or more each year?
*(For persons who usually have cough and/or phlegm)
1. Yes __ 2. No __
IF YES TO 34A
B. For how long have you had at least 1 such episode per year?
Number of years __ Does not apply __
WHEEZING
35A. Does you chest ever sound wheezy or whistling
1. When you have a cold? 1. Yes __ 2. No __
2. Occasionally apart from colds? 1. Yes __ 2. No __
3. Most days or nights? 1. Yes __ 2. No __
IF YES TO 1, 2, or 3 in 35A
B. For how many years has this been present?
Number of years __ Does not apply __
36A. Have you ever had an attack of wheezing that has made you
feel short of breath?
1. Yes __ 2. No __
B. How old were you when you had your first such attack?
Age in years __ Does not apply __
C. Have you had 2 or more such episodes?
1. Yes __ 2. No __ 3. Does not apply __
D. Have you ever required medicine or treatment
for the(se) attack(s)?
1. Yes __ 2. No __ 3. Does not apply __
BREATHLESSNESS
37. If disabled from walking by any condition other
than heart or lung disease, please describe and
proceed to question 39A.
Nature of condition(s)
___________________________________
___________________________________
___________________________________
___________________________________
38A. Are you troubled by shortness of breath when
hurrying on the level or walking up a slight hill?
1. Yes __ 2. No __
IF YES TO 38A
B. Do you have a walk slower than people of your age
on the level because of breathlessness?
1. Yes __ 2. No __ 3. Does not apply __
C. Do you ever have to stop for breath when walking at
your own pace on the level?
1. Yes __ 2. No __ 3. Does not apply __
D. Do you ever have to stop for breath after walking
about 100 yards (or after a few minutes) on the level?
1. Yes __ 2. No __ 3. Does not apply __
E. Are you too breathless to leave the house or
breathless on dressing or climbing one flight of stairs?
1. Yes __ 2. No __ 3. Does not apply __
TOBACCO SMOKING
39A. Have you ever smoked cigarettes? (No means less than 20
packs of cigarettes or 12 oz. of tobacco in a lifetime or
less than 1 cigarette a day for 1 year.)
1. Yes __ 2. No __
IF YES TO 39A
B. Do you now smoke cigarettes (as of one month ago)
1. Yes __ 2. No __ 3. Does not apply __
C. How old were you when you first started regular
cigarette smoking?
Age in years __ Does not apply __
D. If you have stopped smoking cigarettes completely,
how old were you when you stopped?
Age stopped __ Check if still smoking __ Does not apply __
E. How many cigarettes do you smoke per day now?
Cigarettes per day __ Does not apply __
F. On the average of the entire time you smoked, how
many cigarettes did you smoke per day?
Cigarettes per day __ Does not apply __
G. Do or did you inhale the cigarette smoke?
1. Does not apply __
2. Not at all __
4. Moderately __
5. Deeply __
40A. Have you ever smoked a pipe regularly?
(Yes means more than 12 oz. of tobacco in a
lifetime.)
1. Yes __ 2. No __
IF YES TO 40A:
B. 1. How old were you when you started to smoke a pipe regularly?
Age __
2. If you have stopped smoking a pipe completely, how old were
you when you stopped?
Age stopped __
Check if still
smoking pipe __
Does not apply __
C. On the average over the entire time you smoked a pipe,
how much pipe tobacco did you smoke per week?
oz. per week (a standard pouch of tobacco contains 1 1/2 oz.)__
Does not apply __
D. How much pipe tobacco are you smoking now?
oz. per week __
Not currently
smoking a pipe __
E. Do you or did you inhale the pipe smoke?
1. Never smoked __
2. Not at all __
3. Slightly __
4. Moderately __
5. Deeply __
41A. Have you ever smoked cigars regularly?
(Yes means more than 1 cigar a week for a year)
1. Yes __ 2. No __
IF YES TO 41A
FOR PERSONS WHO HAVE EVER SMOKED CIGARS
B. 1. How old were you when you started smoking cigars regularly?
Age __
2. If you have stopped smoking cigars completely, how old were
you when you stopped?
Age stopped __ Check if still smoking cigars __
C. On the average over the entire time you smoked cigars,
how many cigars did you smoke per week?
Does not apply __ Cigars per week __ Does not apply __
D. How many cigars are you smoking per week now?
Cigars per week __ Check if not smoking cigars currently __
E. Do or did you inhale the cigar smoke?
1. Never smoked __
2. Not at all __
3. Slightly __
4. Moderately __
5. Deeply __
Signature ___________________________________ Date ____________________
Part 2
PERIODIC MEDICAL QUESTIONNAIRE
1. NAME ________________________
2. SOCIAL SECURITY #
____ ____ ____ ____ ____ ____ ____ ____ ____
1 2 3 4 5 6 7 8 9
3. CLOCK NUMBER ____ ____ ____ ____ ____ ____
10 11 12 13 14 15
4. PRESENT OCCUPATION ________________________
5. PLANT ________________________
6. ADDRESS ________________________
7. ________________________________
(Zip Code)
8. TELEPHONE NUMBER ________________________
9. INTERVIEWER ________________________
10. DATE ________________________ ____ ____ ____ ____ ____ ____
16 17 18 19 20 21
11. What is your marital status?
1. Single ___ 4. Separated/
2. Married ___ Divorced ___
3. Widowed ___
12. OCCUPATIONAL HISTORY
12A. In the past year, did you work full time (30 hours
per week or more) for 6 months or more?
1. Yes __ 2. No __
IF YES TO 12A:
12B. In the past year, did you work in a dusty job?
1. Yes __ 2. No __ 3. Does not apply__
12C. Was dust exposure:
1. Mild __ 2. Moderate __ 3. Severe __
12D. In the past year, were you exposed to gas or
chemical fumes in your work?
1. Yes __ 2. No __
12E. Was exposure:
1. Mild __ 2. Moderate __ 3. Severe __
12F. In the past year, what was your:
1. Job/occupation? ______________________
2. Position/job title? __________________
13. RECENT MEDICAL HISTORY
13A. Do you consider yourself to be in good heath?
Yes __ No __
IF NO, state reason
______________________________________________________
13B. In the past year, have you developed:
Yes No
Epilepsy? ___ ___
Rheumatic fever? ___ ___
Kidney disease? ___ ___
Bladder disease? ___ ___
Diabetes? ___ ___
Jaundice? ___ ___
Cancer? ___ ___
14. CHEST COLDS AND CHEST ILLNESSES
14A. If you get a cold, does it usually go to your chest?
(Usually means more than 1/2 the time)
1. Yes __ 2. No __ 3. Don't get colds __
15A. During the past year, have you had any chest illnesses
that have kept you off work, indoors at home, or in bed?
1. Yes __ 2. No __ 3. Does Not Apply __
IF YES TO 15A:
15B. Did you produce phlegm with any of these chest illnesses?
1. Yes __ 2. No __ 3. Does Not Apply __
15C. In the past year, how many such illnesses with (increased)
phlegm did you have which lasted a week or more?
Number of illnesses __ No such illnesses __
16. RESPIRATORY SYSTEM
In the past year have you had:
Yes or No Further Comment on Positive
Answers
Asthma ____
Bronchitis ____
Hay Fever ____
Other Allergies ____
Pneumonia ____
Tuberculosis ____
Chest Surgery ____
Other Lung Problems ____
Heart Disease ____
Do you have:
Frequent colds ____
Chronic cough
Shortness of breath when
walking or climbing one
flight of stairs ____
Do you:
Wheeze ____
Cough up phlegm ____
Smoke cigarettes ____
Packs per day ____ How many years ____
____________________ ________________________________
Date Signature